Claims Audit Reveals Underlying Issues

Business Situation

A logistics and transportation company engaged BMI to verify accuracy of medical claims paid by their third-party administrator (“TPA”).

Solution

Utilizing our experienced staff and proprietary AUDiT iQ™ software, BMI set the following objectives:

  • Analyze 100% of all medical claims paid by the TPA during a 6-month period.

  • Test claims against Summary Plan Descriptions, contracts and eligibility records.

  • Identify areas of possible fraud, waste, or abuse and confirm appropriate coordination of benefits.

  • Audit a sample of claims using a hybrid approach consisting of claims samples chosen randomly and focused based on the analysis.

  • Present detailed findings and specific cost-savings recommendations based on the data and audit results.

Audit Findings

  • Incorrect benefit information provided by the TPA to plan participants

  • Failure to apply appropriate prior authorizations when required by the plan

  • Plan language misinterpretation by both the TPA and client.

Audit Outcome

The TPA agreed to initial overpayment amounts exceeding $5,000, however, further investigation of claims samples by the TPA revealed an additional $150,000 in errant claims outside of those sampled through the audit.

At the conclusion of the audit, BMI assigned a specialist to walk through a variety of additional recommendations including both short-term and long-term solutions. Ultimately, this client engaged BMI for annual claims audits to ensure continued claims adjudication accuracy.

Medical Claims Audit, Healthcare Claims AuditRobert Temples